1 Current Evidence-Based Cessation Treatments: Efficacy and Critical Ingredients Saul Shiffman

2 Outcome of Smoking Cessation without Treatment  47% report trying to quit annually  13% of unaided quit efforts don’t last 24 h  Sustained unaided quit rate <3%

Behavioral treatment Pharmacologic treatment

4 Behavioral Treatment  Aimed at assisting behavior change  Practical psycho-educational approach  Based on cognitive-behavioral treatment principles  “Multi-component” mix dominates  Few/no “brand-name” differentiated treatment approaches  Little/no content innovation in 20 years

5 Active Ingredients in Behavioral Programs  Information  Motivation enhancement  Encouragement  Support  Planning & problem- solving  Tips & techniques  Medication support  Process orientation  Structure  Conceptual  Temporal  A specific, step-by-step, pathway to quitting  Contact, engagement, caring  Lifestyle change

6 Effectiveness of Behavioral Treatment Components Source: AHRQ analysis: 2000 * Significantly better than nothing Guess which treatment is no longer in current use

7 More is Better Source: AHRQ analysis: 2000

8 Developments in Behavioral Treatment  Little/no content innovation  Innovations in delivery modality & dissemination  Channels  Media  Providers  Packaging  Duration

9 The Old & New Models of Behavioral Treatment Old wayNew way ApproachCognitive- behavioral MediumFace-2-facePhone, web Delivery model CentralDe-centralized ProviderSemi-ProPara-pro, computer ScriptingAd-libScripted IntensityHighLow-Medium MedicationNegativeIntegrate

10 Some Low-Intensity, Convenient Forms Are Ineffective Source: AHRQ analysis: 2000

11 Effectiveness Rises with Intensity Source: AHRQ analysis: 2000

12 Targeting to Groups  By gender, ethnicity, age, disease, etc, etc  No evidence they require different approaches  Targeted materials may be more appealing  Situations that affect the challenge & need may need different approach  e.g., pregnancy, acute abstinence in hospital

13 Tailoring to Individuals  One size does not fit all  Assess user  Tailor content, emphasis, sequence to individual characteristics and needs  Model what a counselor would do  Greater utilization, satisfaction  Improved efficacy

14 Behavioral treatment Pharmacologic treatment

15 Pharmacological Treatment  Meant to address dependence-related symptoms  Nicotine Replacement Therapy (NRT)  Patch  Gum  Lozenge  Puffer  Nasal spray  Bupropion  New compounds, approaches coming (Frank Vocci) OTC

16 All Medications Effective; About Equally Effective Source: AHRQ analysis: 2000 Studies vary in populations, behavioral intervention, and length of follow-up

17 Combining Medications Enhances Efficacy Source: AHRQ analysis: 2000 No combination approved by FDA gum, puffer, nasal spray

18 Estimated Assisted Quit Attempts (in thousands) Innovation in Dissemination: OTC Marketing Increased Utilization Burton et al, MMWR, 2000 Patch mania OTC switch Zyban intro Nasal Spray

19 Behavioral treatment Pharmacologic treatment

20 Silagy meta-analysis Pharmacological & Behavioral Treatments: Additive Effects Pharm RR = 1.9 Pharm RR = 1.5 Beh RR = 1.7 Beh RR = 1.9

21 Treatment Options: Approximate Effectiveness

22 Impact of Treatment Depends on Utilization Impact (# of quits) = Efficacy (% quit) X Utilization (# using method)

23 Treatment Options: Most Effective are Least Used 72% 11% 7% 8%1% Least effective methods most used

24 Even Among NRT Users Compliance is Poor – and it Matters Average nicotine gum use ~ 4/day

25 Status of Cessation Treatment and Goals for Change Efficacy LowHigh Reach LowPresent High

26 Barriers to Treatment Use Behavioral Tx  Disconnect on mechanism  Don’t see a need  Injury to esteem  Doubt efficacy  Cost  Mostly non-cash Pharmacological Tx  Disconnect on mechanism  Don’t see a need  Injury to esteem  Doubt efficacy  Doubt safety  Cost  Mixed empirical support

27 We Are Reaching Only The Tip of the Iceberg Not currently interested in quitting 56% Interested in quitting, not ready to quit now 26% Preparing to try quitting 13% Actually trying to quit 5% Sources: NHIS 2000, DiClemente et al, 1991 Our Church of Perpetual Abstinence

28 Building Demand  “Build it, they will come”  Marketing: product, positioning, packaging, promotion  Figure out what people want  Explain what it is  Explain why they need it  Make it pleasant, palatable, effective  Make it cool  Different strokes for different folks  Make it, attractive, accessible, & convenient  Promote it (repeatedly)  Maintain a continuing relationship & system of care – not!

NOT!